Provider Demographics
NPI:1134640725
Name:BRUBAKER, STACY ALLYN
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:ALLYN
Last Name:BRUBAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4229 PEARL RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44109-4218
Mailing Address - Country:US
Mailing Address - Phone:216-205-4000
Mailing Address - Fax:
Practice Address - Street 1:4229 PEARL RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-4218
Practice Address - Country:US
Practice Address - Phone:216-205-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-04
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH19071363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology